"*" indicates required fields Firm InformationFirm Name* Contact Name* Firm Address (including City, State & Zip Code)* Phone Number*Email Address* HiddenInfo BreakAttorneys and EmployeesRepeaterLawyer Name First Last Florida Bar Number Number of Years With the FirmBoard Certified? Yes No Add LawyerRemove LawyerNumber of Non-Lawyer Employees on the Firm*HiddenPractice/Attorney breakPractice InformationCurrently Insured* Yes No If Yes, what is the Retroactive Date? Own a Title Company?* Yes No Limits of Liability per Claim/Total Limit* $100,000/$300,000 $250,000/$500,000 $500,000/$1,000,000 $1,000,000/$1,000,000 Other Deductible* $2,500 $5,000 $10,000 Top Three Counties in Which 30% or More of Your Practice Is Based1. County Name1. Percentage2. County Name (Optional)2. Percentage (Optional)3. County Name (Optional)3. Percentage (Optional)Percentage of Practice Out of State Three Major Areas of Practice and Percentages1. Area of Practice1. Percentage2. Area of Practice (Optional)2. Percentage (Optional)3. Area of Practice (Optional)3. Percentage (Optional)HiddenPractice Info BreakClaims/Discipline InformationNumber of Reported Incidents and/or Claims in Last 5 Years Number of Disciplinary Proceedings Before Any Bar within the Past 5 YearsHiddenClaims/Discipline Information BreakCAPTCHA Δ
